Preserving Staffing Resources As a System: Nurses Leading Operations and Efficiency Initiatives.

Nurse leaders have struggled for generations with using the right staff in appropriate roles and numbers to optimally cover patient care services and yet preserve salary dollars when possible. The Baptist Health system identified opportunities to enhance communication across facilities and encouraged executives and department leaders to work together to achieve common goals of efficiency and quality. Baptist Health created an operations and efficiency council with representation from each of the seven hospitals in the system, as well as corporate leaders and support staff. Beginning in April 2014, the system began consistently exceeding productivity targets and effectively eliminated a $30 million dollar salary variance from the spring of 2013.

Evolution of Paget's disease of bone in adults inheriting SQSTM1 mutations.

CONTEXT: The cause of Paget's disease of bone (PDB) is unknown, but genetic factors, particularly SQSTM1 mutations, and environmental factors are important. OBJECTIVE: To investigate the development of PDB in asymptomatic relatives carrying SQSTM1 mutations to determine whether a secular trend towards a less severe phenotype is evident, and to estimate prospectively the rate at which PDB emerged in this genetically susceptible population. DESIGN: We recruited first-degree relatives of patients with PDB [33 adult offspring (mean age 45) and 1 sibling] with a familial SQSTM1 mutation. We determined the presence of PDB with skeletal scintiscans and confirmatory radiographs. Those negative for PDB on the initial scan were investigated again a mean 5·1 years later. RESULTS: The initial skeletal scintiscan demonstrated PDB in six subjects; 26 of the remaining 28 unaffected subjects had a second scintiscan, with two new cases of monostotic PDB diagnosed in 134 patient-years of follow-up. In the total eight adult offspring diagnosed with PDB, the age of diagnosis was greater, by at least 10 years, than that in the 21 probands with clinically identified PDB (P = 0·005). In adult offspring who were older at the time of skeletal scintigraphy than their affected parents were at the time of clinical diagnosis, the difference was even more marked (P < 0·001). In adult offspring with PDB, the disease was significantly less extensive than in their affected parent, as judged by alkaline phosphatase and disease extent (P < 0·003). CONCLUSION: These findings suggest a substantial gene-environment interaction: the emergence of PDB in offspring inheriting SQSTM1 mutations is delayed by at least a decade, has a substantially attenuated phenotype and occurs at a low rate between the (mean) ages of 45 and 50 years. The nature of the environmental factor is unknown.

Redesigning the work of case management: testing a predictive model for readmission.

The rising cost of healthcare along with pay-for-performance and bundled-payment initiatives have affirmed the importance of case management in today's healthcare market. Case managers have historically functioned as gatekeepers regarding patient length of stay (LOS) and cost per case. While LOS and cost of care remain important components of the case manager's responsibilities, at present they have evolved to a much broader role that includes prevention of readmissions and successful transition through the continuum of care. Medicare beneficiaries readmitted to the hospital within 30 days of discharge are thought to cost the healthcare system $17.4 billion annually. In today's hospitals, case managers are being asked to address this issue with systems and processes developed only as discharge facilitation models. Case managers at one acute care organization recognized the need to move beyond the traditional case management roles and activities related to discharge planning, utilization review, and LOS management. Effective transition from hospital to home or supportive agency is a major component of this case management model.

Recombinant osteoprotegerin for juvenile Paget's disease.

Juvenile Paget's disease, a genetic bone disease characterized by accelerated bone turnover, results from inactivating mutations in the gene encoding osteoprotegerin--a key regulator of osteoclastogenesis. The effects of recombinant osteoprotegerin were investigated in two adult siblings with juvenile Paget's disease. Bone resorption (assessed by N-telopeptide excretion) was suppressed by once-weekly subcutaneous doses of 0.3 to 0.4 mg per kilogram of body weight. After 15 months of treatment, radial bone mass increased in one patient by 9 percent and in the other by 30 percent, skeletal bisphosphonate retention decreased by 37 percent and 55 percent, respectively, and there was radiographic improvement. Apart from mild hypocalcemia and hypophosphatemia, no apparent adverse events occurred.

Comparative responses of bone turnover markers to bisphosphonate therapy in Paget's disease of bone.

The measurement of biochemical markers of bone turnover is integral to the diagnosis and management of Paget's disease. Recently, there has been a proliferation of new markers and a move to carry out existing assays on automated platforms. We have assessed the performance of seven currently available markers in 20 patients with Paget's disease undergoing ibandronate therapy (6 or 12 mg) and in nine placebo-treated controls. Samples were collected at baseline and 6 months following intervention. The mean reductions in serum markers following treatment with either dose of ibandronate were: total alkaline phosphatase (AP; Roche Modular) 70%, bone AP (Beckman Access, Ostase) 80%, osteocalcin (Roche Elecsys 2010) 33%, beta-C-terminal telopeptide of type I collagen (betaCTX; Roche Elecsys 2010) 50%, and procollagen-N-terminal peptide (P1NP; Roche Elecsys 2010) 80%. For urine markers the reductions were: free deoxypyridinoline/creatinine (fDPD/creat) (DPC Immulite 2000) 36%, and N-telopeptide/creatinine (NTX/creat) (Osteomark) 81%. Total AP, bone AP, P1NP, and NTX all showed >95% of subjects to have abnormal values at baseline, reducing to 15-30% following treatment, and these treatment effects were highly significant (P < or = 0.0005), except for NTX (P = 0.02). The poorer precision of NTX reduced its utility. Baseline sensitivity was lower for the other markers (osteocalcin 68% of subjects abnormal, fDPD 22%, betaCTX 50%). Total AP, bone AP, and P1NP are suitable osteoblast markers for monitoring bisphosphonate therapy in Paget's disease, with performance approaching that of bone scintigraphy. NTX is less sensitive in detecting the effects of therapy, but is the best performing bone resorption marker. There is no clear evidence from this study that any of these newer markers are superior to total AP in assessing patients with this severity of Paget's disease.